Introduction
Concern over medical student mental health and well-being is not a recent phenomenon. Beginning in 2005, a series of studies and articles by researchers at Mayo Clinic cast light on a topic that had previously been largely ignored (Dyrbye et al. Citation2005, Citation2008; Dyrbye, Thomas, Huntington, et al. Citation2006). High rates of depression, anxiety, burnout, and suicidal ideation among medical students have been found in systematic reviews and multi-institutional research (Dyrbye, Thomas, Shanafelt Citation2006; Dyrbye et al. Citation2010, Citation2011; Erschens et al. Citation2019). The response from medical educators across the globe has been substantial with a veritable explosion of research, commentaries, position statements, and interventions.
Despite this attention, and long before the stresses of the Covid pandemic emerged, progress in improving the mental health of medical students remains frustratingly slow. A number of educational and societal trends appear to be contributing to the recalcitrance of the problem. Some of these precede medical school and include societal trends, changes in the educational systems in high school and universities, and the attributes of students themselves are likely contributors to medical students’ mental health challenges. These challenges are then exacerbated by a demanding educational environment in medical school. Longstanding issues within medical education and medicine include a culture of perfectionism, an unwavering attachment to and unrealistic concept of academic rigor, challenges in adopting effective interventions, power dynamics within medical school administration, and the ongoing crisis of faculty and resident distress and burnout.
In this commentary, the authors explore key areas that they propose are pivotal to both the development of the ongoing medical student mental health crisis and the persistence of the problem over time. They will review: (1). evidence that the mental health of medical students is not improving, (2) societal and educational trends that have contributed to the ongoing crisis, (3) the culture of medical education and medicine, (4) the increase in psychological vulnerabilities among medical students, and (5) the locus of control, organisational and governance structure in medical schools. The authors close with recommendations for action to address this continuing crisis.
Evidence that the mental health of medical students is not improving
The most comprehensive national medical student well-being data in the United States (US) can be found in reports from the Association of American Medical Colleges (AAMC) Year 2 Questionnaire [Y2Q] (Association of American Medical Colleges Citation2022a) and Graduation Questionnaire [GQ] (Association of American Medical Colleges Citation2022b). The Y2Q and GQ ask respondents to rate their burnout [subscales of disengagement and exhaustion from the Oldenburg Burnout Inventory] (Halbesleben and Demerouti Citation2007), and perceived stress (Y2Q only). From 2016 to 2021, mean levels of perceived stress, disengagement, and exhaustion on the Y2Q worsened, while levels on the GQ were similarly degraded and remained so over the same period. These trends existed before, but were exacerbated by the pandemic.
A global challenge
Mental health issues in medical students is a global concern. A meta-analysis of 69 studies from the Middle East, Europe, North and South America, Oceania and Africa analysed the prevalence of anxiety in medical students (Quek et al. Citation2019). Findings showed that one in three medical students globally have anxiety with a prevalence rate of 33.8%, which is substantially higher than the general population. In China a large multi-institutional study of 22 universities found deliberate self-harm among medical college students was caused by uncertainty stress and difficulty in coping at a prevalence of 9.6% which is higher than that reported in the US and UK (Wu et al. Citation2016). The prevalence of psychological distress in medical students found that students across 12 countries scored high to very high on validated measures of psychological distress including burnout (Molodynski et al. Citation2021). Research by the British Medical Association surveyed 4347 medical students and also found high rates of formally diagnosed mental health conditions (Bhugra et al. Citation2019). A smaller study in Hong Kong showed that 87 and 97% of students screened positive for minor psychiatric disorders and burnout respectively (Chau et al. Citation2019). In New Zealand, a study of two medical schools found burnout rates between 68 and 77% (Farrell et al. Citation2019). Canada also reports comparable trends. A 2017 study by the Canadian Federation of Medical Students showed over a third of students met the criteria for burnout (Glauser Citation2017). The prevalence and similarity of these global findings strongly suggests that there are common worrying factors associated with studying to become a doctor.
Societal and educational trends that have contributed to the ongoing crisis
A number of societal and educational trends are likely contributing to the persistent problem. This includes declining mental health of high school and college students, changes in education preceding medical school, and changes in societal culture and values.
Declining mental health of adolescents and college students
Rates of mental illness of adolescents and college students in the US have shown a continuous increase in recent years (Twenge et al. Citation2019). Nationally, the rate of major depressive episodes in 12 to 17 year-olds increased from 9.1% in 2010 to 14.8% in 2017 – a 63% rise. In 2019, more than 1 in 3 high school students reported experiencing such persistent feelings of sadness or hopelessness during the past year that they couldn’t participate in their regular activities - a 40% increase since 2009 (Centers for Disease Control (CDC) and Prevention Citation2019). College students have not fared better. The emotional health of entering college students in the US as measured by the Cooperative Institutional Research Program (CIRP) Freshman Survey [https://www.icpsr.umich.edu/web/ICPSR/series/21], has shown continuous decline from 1985 to 2019 (Stolzenberg et al. Citation2020) and in 2019, a national survey of college students found a stunning 67.6% screened positive for moderate or serious psychological distress (American College Health Association (ACHA) Citation2020).
Changes in education preceding medical school
Higher education around the world underwent significant growth after the Second World War. From the 1950s onward, this growth made a university education more accessible to everyone (Parker Citation2020). By the 1970s, a significant increase in the numbers of college enrolments established what we now call ‘first generation’ students. Furthermore, female enrolments jumped from a third to over half of what they were prior to 1980. Research shows that female and first-generation students report higher levels of anxiety, meaning that these demographic shifts contributed to the initial increase in levels of anxiety in college (Stearns Citation2022; Noel et al. Citation2023).
Consequently, since the late 1990s, universities and medical schools gradually became more competitive. Institutions became fiscally driven by agendas toward competition for the best students to boost rankings that contribute to a marked increase in pressure on applicants to present the most competitive college application possible. In the 1960s, hopeful college students applied to only one or two institutions but by 2006 applying to three or more was the norm, and the number schools applied to has continued to trend upward creating an ever increasing sense of competition. A steady increase in the number of students taking entrance exams also occurred as did the number taking practice tests as early as middle school (Hoxby Citation2009). Over time, these phenomena likely ushered in the rise of testing anxiety.
Secondary (and primary) education was not exempt from the pressures and consequences of these changes. High schools are reliant in large part on student performance and college acceptance rates as measures of success and prestige. This competitive environment produced growing academic demands and pressure on secondary students and may be responsible for the formation of ‘problematic mindsets’ such as an unhealthy comparison to others, seeing performance as identity, self-blame, and maladaptive perfectionism to name a few (Slavin Citation2021). This increase in competition and pressure to achieve, coincident with the unrelenting presence of social media encouraging comparison to others, are likely contributing to the mental health crisis seen in adolescents (Curran and Hill Citation2019; Twenge et al. Citation2019). These pressures continue unabated into the university premedical years, so that some students have experienced eight years or more of persistent academic stress, competition, and unhealthy comparison to their peers before they enter medicine.
Societal culture influence
Students today are the first generation to grow up in a society based on principles of neoliberalism embraced by politicians of the late twentieth century. We have experienced in the last 50 years an erosion of civic responsibility and a focus on self-interest and competition (Curran and Hill Citation2019). We live in a market-based society that encourages evaluation and competition in a variety of ways. This extends to the largely unavoidable influence of social media, which encourages often unrealistic comparison to others and a maladaptive form of perfectionism. Alongside an increasingly competitive education system that constantly ranks individuals and connects academic performance with personal worth, it is unsurprising that high school and college student mental health continues to decline. Added to these demands are rising trends in unrealistic expectations and criticism from parents for their child towards competition and achievement standards (Soenens et al. Citation2005; Curran and Hill Citation2022).
In the US, life goals and values of students have also changed significantly in recent years toward a greater focus on self. Higher proportions of entering freshman students (84.3% in 2019) endorse being well-off financially as an essential or very important goal while fewer (49.8% in 2019) feel the same about developing a meaningful philosophy of life (Stolzenberg et al. Citation2020). Personal characteristics such as motivation and expectations of medical students have also changed dramatically since the 1960s. Research shows that major life goals changed substantially from philosophical and altruistic to being well off financially which coincided with a stark increase in personal ambition. Increasingly students expect to get top grades while spending less time studying (Stearns Citation2022).
The reality is that our current cohorts of students are likely entering medical school with high rates of stress and anxiety, personal histories of intense academic competition, an overall increased focus on their own success and financial well-being, and mindsets that increase their vulnerability to the specific challenges of medical school. These factors will likely make progress with medical student well-being challenging.
The culture of medicine and medical education
If societal culture has an impact on students’ vulnerability to poor mental health before they reach medical school, then a major concern is that they are entering a culture that may develop or exacerbate poor mental health. Conversations about the need to address medical student well-being eventually blames ‘the culture of medicine.’ Yet, what do we mean by that term and how might it relate to student and physician well-being?
Shanafelt et al. (Citation2019, p. 1556), gives a pertinent definition of culture which ‘refers to shared and fundamental beliefs of a group that are so widely accepted that they are implicit and often no longer recognized.’ More dynamic definitions emphasize culture as processes through which beliefs and practices are affected by social contexts and power relationships. These definitions identify defining terms that help us understand how, despite years of attention to improving mental well-being across the medical education continuum, there is little change.
It is surprising that as a healing profession, medicine inculcates, almost an ethos of overwork and unhealthy self-care. Certainly, it is the culture that dictates we emphasise the importance of self-care, maintaining personal interests and social relationships alongside the provision and constant reminders of endless mental health resources and support services. This ‘mixed message’ suggests a need for support but lays the onus to access that support on the student and does little to remove the underlying causes. It is the culture that denies the stigma that remains strong in medicine (Dyrbye et al. Citation2008; Bynum and Sukhera Citation2021). And it is the culture that indoctrinates an almost insidious vulnerability to negative mindsets that demand perfectionism, and disregards personal feelings and self-care as weak. Sadly, well-being as part of medical education culture has a history that devoted little attention to the matter. As stated by Bynum and Sukhera Citation2021 (p. 621), ‘Perfectionist tendencies are built into the culture of medicine. Medical learners are products of an educational system that relies heavily on high-stakes objective performance measures such as grades and standardized examination scores.’
Psychological vulnerabilities of medical students
Schools devote substantial funding and resources in a highly competitive high stakes process to choose the ‘right’ students to become doctors. Yet this process is arguably what drives the very crises we are dealing with. As noted, many students begin medical school with long-standing problematic mindsets. These high achieving students are accustomed to being the best at just about everything and attribute this to working hard and striving for perfection to meet expected performance measures. These mindsets are likely to begin in secondary school and further develop in pre-med programs at university. By the time they enter medical school, the need to be perfect is often part of their identity and may lead to a maladaptive form of perfectionism (Hu et al. Citation2019; Bynum and Sukhera Citation2021). The dysfunctional patterns of thinking associated with maladaptive perfectionism are related to imposter phenomenon and both have been found to correlate with higher depression and anxiety scores in medical students (Hu et al. Citation2019). When combined with the reality that most first year medical students will discover that they are no longer top of their class, in fact only average or even below average, the experience of academic struggle may be unsettling. These early medical school experiences may further develop feelings of anxiety and undermine self-worth.
Locus of control: organisational and governance structures in medical schools
Much of modern medical education lingers in tradition. An example is how faculty in many medical schools remain wedded to the concept of academic rigor, which often translates to the expectation that students learn an overwhelming amount of material, particularly in the pre-clinical years. Germaine to this commentary is the pre-clinical years. The pressure of having to absorb and retain (even temporarily), large amounts of information has been exacerbated by a trend, at least in the US, to progressively shorten the preclinical curricular period so students are forced to learn more in less time. This occurs when even the most confident first year medical student is navigating their place in the hierarchy of fellow beginners while striving to maintain their perfect achievement status. Yet it doesn’t have to be this way. Evidence based models exist in the pre-clerkship years, that can serve as guides to action.
A number of studies have shown that pass/fail grading in the pre-clinical phase contributes to student well-being. At Saint Louis University, simple and inexpensive changes produced improvements across a range of interventions. These included a change to pass/fail grading, modest reductions in content and class time, increased time for electives and a brief resilience curriculum focusing on problematic mindsets like impostor phenomenon and maladaptive perfectionism. These initiatives led to 80% reductions in depression and anxiety in pre-clerkship students as well as improvements in United States Medical Licencing Exam (USMLE) Step 1 performance with higher scores paralleling an increase nationally during this period. Furthermore, the USMLE failure rate dropped by half, while there was no change in the failure rate nationally over this same period. Yet this model has been slow to be embraced at a significant number of schools (Slavin et al. Citation2014). The reasons why are not entirely clear but likely include a number of factors such as the political challenges to decrease curricular material and time, a tendency of medical educators to embrace new curricular trends (such as shortened preclinical periods), and challenges in dissemination of new well-being approaches.
Those charged with the responsibility for medical student mental health and well-being are most likely to sit in Student Affairs Offices and may have little influence over curricular issues and policies that are the primary drivers of poor mental health. They are often left to devise interventions that focus primarily on the individual such as meditation and yoga, which may be helpful, but will never be enough to address the mental health needs of students. Similarly, well-being committees and task forces tend to focus on interventions such as social events, peer support, mental health ‘first aid’ that are all reasonable and appropriate interventions, but that largely ignore the environmental drivers of student distress.
The clerkship year poses greater challenges to improving student well-being because of the nature of the forces driving student stress and distress. In one study, the most highly rated factors contributing to student stress were working with unhappy faculty, unhappy residents, and the subjectivity of grading (Slavin and Chibnall Citation2017). Much more needs to be done to improve resident and faculty mental health. We can’t expect students to flourish in environments where their supervisors are not. Assessment presents another difficult issue. While we need to continue to improve assessment and grading of students in the clerkship year, progress is likely to remain difficult given time pressures that faculty and residents face, inadequate training in observation and assessment, and the ongoing threat of implicit bias that can impact the reliability and accuracy of clinical evaluations.
Finally, medical school inaction may be occurring for a very simple reason - schools can get away with it. Competition for medical school admission globally remains very high and schools do not have difficulty filling the seats, even if they offer a less than hospitable and nurturing environment. Unlike board scores and match rates, well-being metrics are not generally gathered or made publicly available, and quotas can be filled even if students are dissatisfied.
Recommendations for change
Shanafelt et al. (Citation2019) speaks of ‘managed evolution’ which is deliberately making changes to longstanding practices and beliefs. This approach is necessary in mature cultures such as medicine. Of course, this is the crux of the problem - getting the very people who stubbornly refuse change to accept it even when a change has been shown to be successful e.g. reducing pre-clinical year content (Hu et al. Citation2019).
Everyone involved in medical education should examine their roles and realm of influence
Faculty teaching in the preclinical years can reduce content overload and adopt less punitive assessment strategies, which require the student to take responsibility for their learning. Reducing competition and providing clarity about expectations can encourage a sense of responsibility in students to strive for and achieve their goals.
Faculty in the clinical years can work to transcend their frustrations with clinical practice and create supportive and inclusive learning environments. We need to redouble our efforts to create better working conditions for residents and faculty so that they are better positioned to create humane and supportive learning environments for students. Burned-out and frustrated faculty are not only poor role models but a poor reflection on the medicine as an entity. This sends mixed messages to students in regard to the career they are entering.
Focus on the entirety of the medical school experience
Curriculum deans and committees should examine every potential curricular change through the lens of student well-being. This includes the practicality of and resources available to enact changes to assessment, curriculum structure, and content overload inherent in medical education, and importantly faculty support and development. Provision of ample resources to enact planned changes should be in place and enacted so the sense of achievement is shared amongst the faculty while strengthening teamwork and a collective sense of accomplishment
Recognise the impact that the entirety of the health workplace provides across the continuum of the medical education culture our students’ experience. Universities, medical schools, and hospitals need to widen their lens on well-being across the broad network that ultimately supports our students from medical school to residency and speciality training (Rotenstein et al. Citation2022).
Nurture an environment of shared responsibility for mental health in our students
Approaches to individually focused tools and strategies for students such as exercise, nutrition, and social events to enhance belonging should continue but should also be supplemented by workshops to help students develop cognitive restructuring techniques to better manage problematic mindsets. We must make it easier for students to help themselves by learning and adopting self-care habits that they can build on and sustain across their careers as well as role-model to their patients.
Robust mental health services are essential but rarely address the root problem. They also put the burden on the student to identify themselves as someone who needs help. More attention is needed to reduce the feelings of stigma that remain prevalent in medicine of which students are keenly aware. As much as we may wish to deny its presence, the air of stigma permeates the medical education environment (Bynum and Sukhera Citation2021). Covert feelings of stigma feed problematic mindsets and are likely to linger in the medical environment as they have for decades. In the meantime, we must help students recognise and find their personal balance to cope with their feelings and circumstances. Educators and the medical community must share the responsibility for changing this environment into one that nurtures better mental health amongst our students and staff.
Addressing pipeline issues
Finally, in our efforts to improve medical student mental health we must recognise that the issues develop along a pipeline and occur both upstream and downstream. It is important to recognise that in many countries, downstream issues, such as the applicants for speciality training far outnumber the available places, is a significant cause of concern. Nevertheless, many solutions to the medical student mental health problem need to occur upstream. We must question if the pathway into medicine i.e. secondary, and tertiary education, can be less competitive and demanding, thereby reducing unhealthy pressure on students who aspire to become doctors. Fundamental change is needed in secondary and university education to reduce the pressure of getting top grades, which fuels a constant comparison with others and drives psychological distress. There is an essential need for students, and educators, to understand the purpose and relevance of assessment as the means to improve and develop a healthy attitude to their personal academic performance, not as a means to rank oneself against classmates. Given that transitional stages in education, such as starting medical school, are associated with heightened feelings of stress and uncertainty, it is of paramount importance that our students arrive less exhausted and traumatized by our educational systems. This is a huge and complicated culture shift but one that is worth our serious attention – now.
Conclusion
Progress in addressing the mental health crisis in medical students has been negligible despite attention to the crisis for more than 15 years. New efforts and strategies are needed to better address the problem and overcome the barriers to change that exist. The medical education community globally needs to continue to prioritise student mental health and enact changes that produce healthier and more supportive learning environments, while also providing students with the skills needed to manage the significant stresses inherent in medical practice and life.
Glossary
Problematic mindsets: A problematic mindset is a state of mind where distorted thoughts and negative beliefs keep us from dealing with problems in an effective and healthy manner. This may develop into a negative inner dialogue that not only stops us from finding a solution to a problem but can spiral into distorted beliefs and lead to more serious mental health concerns.
Cognitive restructuring: Cognitive restructuring is a group of techniques that help people notice and change irrational: Thoughts and negative thinking patterns. It is a method to help individuals transform the way they think about negative things with the goal of reducing self-defeating thinking patterns and encourage a healthier outlook. It is commonly used in cognitive behavioral therapy.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Additional information
Funding
Notes on contributors
Diann S. Eley
Diann S. Eley, MSc, PhD, is a Professor and Director of MD Student Research in the Academy for Medical Education, Medical School, University of Queensland, Australia.
Stuart J. Slavin
Stuart J. Slavin, MD, Med, is Vice President for Well-Being at the Accreditation Council for Graduate Medical Education, Chicago, Illinois, USA.
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